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Applications Will Be Processed When SubmittedProperly Comp°etea. tiesure TO01911 r11WANN••.a••�••• <br /> [FOR oFFlrr use:. __ APPLICATION <br /> (Fc•' �li Transferable, Revocable, Suspendabie) `P�Mp&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) <br /> ° <br /> Application is hereby madetotheSan Joaquin Local Health Districtfora permitto construct and/or install thework herein described.This application is t <br /> made in compliance with San oa uirl.Coun Ordinance No. 1862 and the rules and regulations of the San Jo, uin Local Health District. <br /> .-� City/Town <br /> Exact Site Address Ce @ r 3 <br /> Phone e-33 <br /> Owner's Name <br /> City t <br /> Address -� 1 <br /> Contractor's Name License# Business <br /> Phone hon e r �, <br /> Emergency Phone <br /> Contractor's Address <br /> rJ / <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No �] <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER 13 PUMP INSTALLATION PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy y <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well r <br /> INTENDED USE TYPE OF WELL <br /> E] INDUSTRIAL Cl CABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing r <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> l ❑ IRRIGATION ❑ GRAVEL PACK ; Depth of Grout Seal <br /> t ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other information <br /> ❑ GEOPHYSICAL ` Surface Seal Installed By: <br /> s PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: State Work Dane <br /> h <br /> PUMP REPAIR: ❑ State Work Hone w <br /> DESTRUCTION OF WELL: Well Diameter ' Approximate Depth <br /> I Describe Material and Procedure_ <br /> f I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> I ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> Homeowner or licensed agent's signature certifies the following:"1 certify that in the performance of'thework forwhich this permit <br /> is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will call for a Grout spection prior to grouting and,a final ins pec tio <br /> - Title: <br /> r Daley <br /> Signed X <br /> (Draw Plot Plan on Rve,,, de) <br /> FOR DEPARTMENT USE ONLY <br /> i <br /> PRASE I / �., 3 <br /> - /-�'C) <br /> Application Accepted By �� ��=� Hate , <br /> Additional Comments: <br /> Phase 11 Grout Inspection se III Final pection <br /> Inspection By <br /> Date Inspection B ate �� l <br /> Fee Is Due: Cl ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January-31 July 1 &Received By July 31 <br /> - REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $1 AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS F <br /> • PENALTY <br /> OTHER <br /> S <br /> OTHER <br /> Date Receipt No. °Permit No. Issua ce Date Mailed Delivered <br /> Received by - <br /> _ 1601'E.HAZELTON AVE.,P.O.Sox 20a9 STOGKTON,CA 8520 <br /> APPLICANT—RETURN ALL COPIES TO:� ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />